Consumer Reports Ranks Bypass Surgery Centers

The group responsible for Consumer Reports on everything from vacuums to cars today released a report card for CABG outcomes at roughly 20% of the nation's heart surgery centers.

The ratings identify the 50 top-performing centers based on risk-adjusted clinical data submitted to the Society of Thoracic Surgeons registry.

This list, which was posted online, included Massachusetts General Hospital and a group at George Washington University Hospital but most of the centers were community medical centers. The ranking will also be published in the October print edition of Consumer Reports.

Mass General and the surgeons group at George Washington were among 50 centers that received three stars -- the top rating.

Only five of the 221 surgical groups that agreed to public release of their CABG outcomes data garnered a below average or one star rating on the three-star scale, according to Consumer Reports publisher Consumer Union.

A Perspective article in the New England Journal of Medicine called release of the ratings "a watershed event in healthcare accountability."

In the article, timed to the release of the doctor ratings, Timothy G. Ferris, MD, MPH, and David F. Torchiana, MD, both of Massachusetts General Hospital in Boston (a three-star center), explained that the quality of data that went into the scores far exceeds anything that healthcare consumers have had access to before in any field on a national basis.

A few states, notably New York and Pennsylvania, already provide access to clinical outcomes data.

The STS Adult Cardiac Surgery Database, though, includes voluntary reporting by more than 90% of the approximately 1,100 cardiac surgery programs in the nation. The data are collected from patient charts, which the report card aggregates into a physician group-level performance score on 11 rigorously-validated measures.

Consumers get to see not only a center's total score but also the following:

30-day survival (such as "patients have a 98% chance of surviving at least 30 days after the procedure and of being discharged from the hospital")

Complications (such as "patients have an 89% chance of avoiding all five of the major complications")

Use of appropriate medications, such as aspirin, statins, and beta-blockers (such as "patients have a 90% chance of receiving all four of the recommended medications")

Surgical technique, such as use of an internal thoracic artery for the graft (such as "patients have a 98% chance of receiving at least one optimal surgical graft")

"This is objective data that is about as good as you can get," David M. Shahian, MD, also of Massachusetts General Hospital, said in an interview.

As chair of the STS committee responsible for the database, he worked extensively with Consumer Union on the public release of the data his organization has been collecting since 1989.

One of the big concerns for physicians is getting misclassified in these public ratings, which the state-based experience has shown leads providers to shy away from taking on the highest-risk patients, who although they may stand to benefit most from CABG also carry higher risk of mortality that could ding a physician's numbers.

Cardiac surgeons should instead see public reporting of their results as an incentive to excel, Shahian urged.

"We want to assure our providers that our methods of adjusting for patient severity are quite good," he told MedPage Today in an interview.

Doctor ratings available online previously have relied on patient reviews (which are notoriously subject to selection bias for only the most positive and negative impressions), reputation, or administrative data that rarely takes into account how sick the patient population treated was, Consumer Union noted in a press release.

However, the new reporting card still falls short in some respects, Ferris and Torchiana noted.

Selective participation of programs -- only about a quarter of those in the database allowed public release of outcomes -- as well as lack of physician-specific ratings or long-term outcome reporting are likely to draw criticism, they wrote in the editorial.

Despite state-required reporting in some areas, centers there may still have been reluctant to release their full data.

Ferris explained that states typically provide only mortality figures, which vary little. The primary determinant of center-to-center variability -- and thus ratings -- is complication rates, which have not been public, he noted.

Advocates of transparency can be expected to pressure nonparticipating cardiac surgery programs, he and Torchiana added in the editorial.

Once the participants test the waters and show others how it works, others are likely to be willing to follow, Shahian said.

In the era of increasing emphasis on transparency and accountability, few surgeons or groups have suggested public reporting is the wrong thing to do, he explained.

"In the new healthcare environment we're in, many if not most [medical professional] societies are going to have to come to grips with this very quickly," Shahian predicted in the interview.

While Ferris agreed, he expressed skepticism that others would find the transition so easy.

CABG has the advantage of being a procedure for which oftentimes people have a choice of providers, that is fairly reproducible, and has relatively layperson-friendly performance measures, he pointed out.

"There aren't a lot of examples of medical services that meet those criteria," he told MedPage Today.

In the end, public reporting data is only useful if used, and many patients likely won't turn to Consumer Reports when choosing a thoracic surgeon, he said.

Patients should use the report card when in a nonemergent situation, Shahian argued.

But "it's only one part," he cautioned. "We want them to still listen to the advice of their referring cardiologists and other physicians caring for them."

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